Provider Demographics
NPI:1477935351
Name:BLACK, NICOLE (PHD, LPC-S, LCDC RPT)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD, LPC-S, LCDC RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 66TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-4875
Mailing Address - Country:US
Mailing Address - Phone:806-712-5225
Mailing Address - Fax:806-722-5225
Practice Address - Street 1:4601 66TH ST STE E
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-4875
Practice Address - Country:US
Practice Address - Phone:806-712-5225
Practice Address - Fax:806-722-5225
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12986101YA0400X
TX71446101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)